Polytechnic University of the Philippines

OPEN UNIVERSITY SYSTEM

OFFICE OF THE REGISTRAR
4th Floor, NALLRC, Mabini Campus, Sta. Mesa, Manila
Tel. 3387409/7167832-35 loc. 325

APPLICATION FOR ADMISSION

Date _____________________

THE EXECUTIVE DIRECTOR

Open University System
This University
Thru: THE REGISTRAR
Open University System
Dear Sir/Madam:

I wish to apply for admission as (please check) [ ]New Student [ ]Transferee this
________Semester, School Year ________________ to take up / continue (please check) [ ]BBrC
[ ]BSEM [ ]PBDIT [ ]MC [ ]MEM [ ]MPA [ ]MSCM [ ]MSIT [ ]NTSP [ ]ETEEAP
course/program in the [ ]School of Distance Education [ ]School of Professional Studies.

I. PERSONAL BACKGROUND

NAME: ___________________, _______________________ _______________ ______________

Last Name First Name Middle Name Maiden (if married)
ADDRESS:_______________________________________________________________________________
PROVINCIAL ADDRESS:___________________________________________________________________
GENDER: [ ]Male [ ]Female CIVIL STATUS: ____________________ NATIONALITY: _______________
DATE OF BIRTH ______________________________ PLACE OF BIRTH ___________________________
COMPANY/AGENCY:______________________________________________________________________
ADDRESS: ______________________________________________________________________________
CONTACT NOS: Residence:__________________________ Mobile No. _________________________
Prov’l Res: __________________________ Mobile No. _________________________
Office: __________________________ Mobile No. _________________________
e-mail address/es:__________________________________________________________

II. EDUCATIONAL BACKGROUND

Units Earned Scholarship/
Degree Year
Level Name of School (if not Academic
Course Graduated
graduated) Honors Rcvd.
ELEMENTARY

SECONDARY
VOCATIONAL/
TRADE SCHOOL
COLLEGE

POST BACC.

GRADUATE
STUDIES

I hereby affirm that all information given herewith are complete and accurate. I am aware that
any or all of the information furnished in this application may be checked against original documents
and that concealing/or giving false information will disqualify me for admission and/or subject me for
dismissal. Furthermore, I agree to finish the course within the prescribed period otherwise this will be
a ground for my honorable dismissal. I agree to abide by the policies, rules and regulations of the
Polytechnic University of the Philippines – Open University System.

_______________________________
Signature over printed name